05020095CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDINGADDRESS:
MORGADO-4 CONST.
122MITNOO 5020095
ER'S NAME:
PERMIT ISSUE DATE
MARK SANTO
PHONE:
SANITARY NO. CONTROL NO.
(408)275-0499
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
1 Mm N
Manby afOfam l 1 aunder provisions of Chapter 9 (mmmcns
oP
with Sudan 7010) of Division 3 off Jac Business an Is
ft Bu nessand Pro(cuians Cmde.d my license s
Ing.." se
f YY 3 P.T
POOL HOUSE
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Dam Contractor
ARCHITECTS DECLARATION
1 undaN+n IDy p M used apublic named,
�rvfasionai
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Lkcivcd
OWNER -BUILDER DECLARATION
j
License Law for the
1 hereby .(Seco That 11. exempt s an the CommunesCock:
703L5. Business and Cade: My city
following won. (S.I,
/
&aions
t alcor, Improve, de stcounty
improve. or cartel, any sotsaury
which reyuirta a permit re cares
Permit
prior ms issuance. almamqulrm theapplicantfor such permitmfileasigmdcomment
the t
that he is Hemmed pummamile. LO ton, the. ummriLIcenso Law (ChapterCodc)9
Sq. Ft. Floor Area
Valu
of Divisions
(mm with Sadlmo 7020) of Division f 3 a(NC Business;Codc).,
a ar
Proon,
$ 9 92
eNd
a Is exa Anyovi
Nat he V emmpt Nem(rom and the ba4 for the alleged emmptim. Any violation of
aged
APN Number
Occupancy
PanC y •7P('
Section 7031.5 by any applicant for a permit Subjects Ne applicant to a civil penalty of
not mom Nan five hundred dollars (M).
❑ 1, as ower orthe property, or my employees with wages as Manacle compensation,
', Required Inspections
will do the work, and the s mcmre is notinm ailed aroffered format, (Sm. 7044, Budmoa;
and Profewmns Cade: The Contractors Limine Law does Out apply m an owner of
prope tywho builds orimproms Ihercan.and who doessuchweek himmlfmrthrough his
Own employees. provided that cash Improvements ace nolime ded oroQered formai. E.
however, Ne building or Improvement is sold within one year of m npledon. Ne owner -
builder will have Ne burden of proving that he did not build or improve for purpose of
sat,.).
❑ I. Or owner or the property. am exclusively mnuaning with licensed mntralers m
cmnstmet tie project (Sec. 7094, Business and Profession, Code) The Cmoacmr's U.
mouse Law dors net apply to an owner of propeony who hui1N or improves thereon. and
who contracts for such projects with amonumtor(m) licensed pursuant to the Commerce,
License law.
❑ I am exempt under See ,B& P C for this mason
Dam
WORKER'S COMPENSATION DECLARATION
1 Manby allies under penally of perjury, one of the following declamtmn,:
❑ I haw and will maintain aCesificae of Conscnt m self -loam for WmImYa Compen.
nation, as provided for by Smdon 3700 of the labor Cade. fm the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workees Compensation Insunnm, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worked Compensation Insurance caller and Policy number /
C.mier.AM 1& /.j Polity No.: � V9d
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section treed not be completed If the permit is fortune hundred dollar ($100
'
or less.)
1 mNry that in Ne performance of the work for which this permit ts Issued. I Nail not
employ any Noon In any manner an as m become subjects the Wmrken' Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: IL arm, making Nia Cci ifiae of Exemption, you should
became Subject m the Worker's Compenmtlon previsions of the Labor Code, you must
forthwitb comply with such provision, Or this permit Shall be deemcE rooked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Nem is. con,ttsction lending agency for tae performance of
bac work for which this permit Is issued (See. 3097, Civ. C.)
Lenders Name
Leuded Address,
1 certify that 1 have mad this application and sum that the show Information u
"
comes. I agme in comply with all city and county ordinances and some laws mlating in
Wilding commission, and hereby auNodm mpmmmWl 1 Of Nu city to now upon th,
,
ahow-mentimed property for impaction purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Ilabilitia, judgments, cats and expenses which may in my way accts, against said City
in consequence of the grunting or this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE EGULATIONS,
^Z'y-0 _Re
_6•
-roofs
Type of Roof
ST{mmm of Appliam/Conuanlm Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant some or handle hamodous mamdai
fined by the Cupertino Municipal Code. Chapter 9. 12. and tie Health and Safety
Sees. 25532(.)? r�aa�A
❑Yat `n"
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit haardnus air contsminants as de0ncd by the Bay Area Air Quality Management
all new materials for inspection.
District?
C3 yes �fu
I have mW the heard., materials requirements under Chapter G95 of the Califor.
rats Hmhk&Safety Cade, Somans 25505, 25533 and 255M. l undenwd bass ifue building
does tort currently haw a temnl Net it ts my responsibility to notify the occupant of Me
requirement% which must be met prior to Issuance or a Certificate of Occupancy_
Signature of Applicant Date
�� 6 Ly a
All roof coverings to be Class "B" or better
OwncrmauNmdvcde
enl Dom